Applications of Preference Assessment Procedures in

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Clin Gerontol. Author manuscript; available in PMC 2012 May 14.
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Clin Gerontol. 2009 ; 32(3): 239–259. doi:10.1080/07317110902895226.
Applications of Preference Assessment Procedures in

Depression and Agitation Management in Elders with Dementia
Leilani Feliciano, Ph.D. and Mary E. Steers, M.A.
University of Colorado at Colorado Springs
Alexandra Elite-Marcandonatou, LCSW, Maura McLane, M.A., and Patricia A. Areán, Ph.D.
University of California, San Francisco
Abstract
Low levels of engagement with leisure activities are commonly seen in older adults with dementia
and may lead to decreased social contact, depressed affect, and agitated behaviors. Adults with
dementia often have difficulty choosing activities when asked directly about preferences due to
cognitive decline, which makes it more difficult to increase their engagement levels. However,
simply presenting leisure items without prior knowledge of preferences may be inefficient and
may not yield desired results. Long-term care staff need more structured and efficient ways to
determine individual preferences and preference assessments (structured choice making
opportunities) may offer a solution. Preference assessments have been used to identify effective
reinforcers for both individuals with developmental disabilities and older adults with dementia and
can provide staff with a brief method for identifying enjoyable activities. This study examined the
utility of using stimuli (identified from preference assessments) in behavioral management
protocols with 11 elders (mean age = 85.6 years) with dementia in a long-term care setting.
Behavioral outcomes of depression and agitation were evaluated at baseline and throughout the
intervention. Results indicated positive improvement in behavioral symptoms in 8 of 11
participants. The utility of using preferred items in behavioral management protocols was
supported for reducing agitated behaviors but was only partially supported for decreasing
depressive symptoms in individuals with dementia.
Keywords
Dementia; preference assessments; depression; agitation management; long-term care
Introduction
More than 2.5 million older adults live in long-term care (LTC) settings (Hawes, Rose, &
Phillips, 1999). Within LTC, approximately 42–67% of elders have some type of dementia
(American Association of Retired Persons, 2001). Dementia refers to a set of neurological
diseases that result in progressive decline in several areas of cognitive functioning including
memory, language, visuospatial skills, and executive functioning (Flashman, Wishart,
Oxman, & Saykin, 2003). Currently about 75% of individuals with dementia display at least
one neuropsychiatric symptom (Lyketsos et al., 2002). Neuropsychiatric Symptoms refer to
disturbances in thought, perception, mood and behavior with apathy (36%), depression
(32%), and agitation/aggression (30%) being reported most often (Lyketsos et al., 2002).
Corresponding Author: Leilani Feliciano, Ph.D. Department of Psychology University of Colorado at Colorado Springs 1420 Austin
Bluffs Parkway, COH5 Colorado Springs, CO 80918 lfelicia@uccs.edu.
Feliciano et al. Page 2
Currently, depression is one of the most common disorders/neuropsychiatric symptoms seen

in LTC (Williams et al., 2006). Between 30 to 50% of individuals with dementia exhibit
depressive symptoms (Mast, 2005), which pose great challenges for caregivers. Individuals
with dementia who exhibit depressive symptoms often are more clinically complex and have
more adverse outcomes (Kales & Mellow, 2003). For example, increased frailty, poorer
quality of life, greater impairment in activities of daily living (ADLs), and greater language
and motor deficits (Williams et al., 2006) are commonly seen in those suffering from both
depression and dementia.
Depressive symptoms can be highly problematic for caregivers, and the challenge of
providing care is exacerbated when the patient shows signs of agitation. Agitation refers to
“inappropriate verbal, vocal, or motor activity” (Cohen-Mansfield, Marx, & Rosenthal,
1989, p.M77) and is quite common in nursing homes, with as many as 93% of residents
exhibiting agitated behaviors in a week (Lyketsos et al., 2000). Agitation is thought to result
from incongruities between the person and the environment (Beck & Vogelpohl, 1999),
which can occur, for example, when the individual is no longer able to process normal levels
of stimulation and becomes overstimulated (Cohen-Mansfield, 2003). Agitation can take the
form of aggressive behaviors (e.g., hitting, kicking), verbal aggression (e.g., swearing,
berating others), inappropriate vocalizations (e.g., screaming, moaning, repetitive
questioning), and inappropriate motor activity (e.g., wandering, pacing). A decreased ability
to engage in activities could also lead to a decrease in sensory stimulation, thus making it
more likely for agitation to occur. Agitated behaviors may occur more frequently because
the behaviors result in increased sensory stimulation and are thus reinforced, increasing the
likelihood of the agitated behavior occurring again in the future. Fisher, Fink, and Loomis
(1993) reported that agitation and depression are two of the most difficult behaviors for
caregivers to manage in LTC settings. Individuals with dementia who exhibit signs of both
agitation and depression account for the greatest use of hospital-based care (Bartels et al.,
2003). Therefore treating depression and agitation in older adults with dementia emerges as
a means of reducing caregiver burden.
Historically, agitation was managed through use of either physical or chemical restraints
(Cohen-Mansfield, Libin, & Marx, 2007). However, neither of these treatment methods
effectively decreases agitation (Sink, Holden, & Yaffe, 2005). Additionally, there are
negative consequences associated with restraints including decreased quality of life, adverse
side effects, and increased risk of death (Schneider, Dagerman, & Insel, 2005). As agitation
may place individuals at an increased risk of harm (Vance et al., 2003), alternative
nonpharmacological interventions for agitation are sorely needed. Therefore, designing
effective interventions for the management of behavior problems has become a global health
concern (Allen-Burge, Stevens, & Burgio, 1999).
As previously mentioned, dementia results in progressive declines in multiple areas of

cognitive function. One significant area involves deficits of executive functioning.
Individuals with dementia lose the ability to plan and sequence events. As a result,
decreased engagement in leisure activities is a common experience for older adults with
dementia, whose levels of engagement wane as the disease progresses. Low levels of
engagement in preferred activities may lead to limited social engagement, depressed affect,
and boredom, as individuals who do not participate often become isolated from their friends,
family, and peers (Engelman, Altus, & Mathews, 1999). Often, depression in individuals
with dementia presents with behavioral symptoms such as anxiety and agitation, and can
exacerbate cognitive impairment. In dementia care settings, offering more activities does not
necessarily increase individuals' levels of engagement. However, if the program's focus is on
optimizing positive behaviors, both engagement and quality of life can be increased (Wood,
Harris, Snider, & Patchel, 2005).

Another cognitive domain affected in dementia with potentially severe consequences is the
individual's ability to verbally communicate his or her needs. The diminished ability, and
eventual inability, to verbalize preferences reduces environmental control and access to
pleasurable stimuli as the individual is unable to express the preference for one stimulus
over another. Caregivers face the challenge of choosing reinforcing stimuli (i.e., enjoyable
objects or activities) for individuals with dementia, which can be difficult if effective
reinforcers have not been identified prior to the individual's loss of the ability to verbalize
his or her preferences. Simply presenting leisure items without prior knowledge of
preferences may be inefficient and may not yield desired results (Staal, Pinkney, & Roane,
2003). Because of the many time demands and burdens placed on LTC staff, there is a need
both for structured and efficient ways of establishing individual preferences. Preference
assessments may offer a solution.
Stimulus preference assessments (SPA) have been used to identify effective reinforcers for
several populations, including those with developmental disabilities (Kuhn, Deleon,
Terlonge, & Goysovich, 2006). This methodology has just recently been successfully
translated for use with older adults with dementia (LeBlanc, Cherup, Feliciano, & Sidener,
2006). The creation and utilization of SPA provides staff with a brief method for identifying
activities that are likely to both engage and please individual patients. In effect, dementia
patients' quality of life can be greatly improved by incorporating prior preferences into care
routines.
SPA can be administered in multiple formats, including basing preferences on caregiver

opinions (indirect) or on patient responses during brief presentations of various stimuli
(direct) (Hagopian, Long, & Rush, 2004). Indirect SPA are conducted by using interviews—
structured and unstructured—or checklists. Once the information is collected, the stimuli are
ranked based on how much the caregiver perceives the patient to prefer each stimulus.
Direct SPA involve exposing the client to stimuli for a brief period of time and recording his
or her engagement with each stimulus (Hagopian et al., 2004). This process is repeated
multiple times until a preference hierarchy is identified. Thus, this strategy effectively
produces an “index of individual preference” for multiple stimuli (LeBlanc et al., 2006).
Finally, the paired-stimulus procedure is a method of direct, approach-based preference
assessment in which stimuli are presented in pairs and the client chooses one of the two. The
preference hierarchy is developed by calculating the percentage of times each stimulus was
selected out of all trials where it was presented (Hagopian et al., 2004). The paired-stimulus
method is preferred over the multiple-stimulus presentation procedure for individuals with
dementia because it reduces the likelihood of stimulus overload (Day, Carreon, & Stump,
2000).
There are multiple administration formats of direct SPA: vocal, tangible, textual, and
pictorial. The most commonly used modalities are vocal and tangible. In the vocal format,
participants are verbally asked, which of two activities they would prefer, and asked to “pick
one”. In the tangible format, items are placed in front of the patient who is asked to choose
one. In all modalities, after each choice is presented, access is given to the chosen item for a
short period. In practice, the tangible modality is often the easiest to accommodate as it
requires less preparatory work than either the textual or the pictorial modalities, and it is not
dependent on cognitive or verbal ability. This may be why research has shown the tangible
modality to be more accurate than other modalities (Conyers et al., 2002).
The present study was designed to investigate the utility of using preference assessments as
part of an intervention in the management of depression and agitation in older adults with
dementia. A paired-stimulus preference assessment was utilized employing the tangible
modality. Behavioral outcomes were evaluated at baseline and throughout the intervention.

It was predicted that increasing engagement with preferred items would result in decreased
levels of agitation and depression.
Methods
Setting and participants
This study was conducted within six residential LTC facilities for the elderly in the San
Francisco Bay Area of California. These facilities were recruited as part of a larger study
examining methods for disseminating evidenced based practices into community settings.
Participants from this study were referred from all six facilities. Facility demographics are
provided in Table 1. Therapists for this study included two master's level clinicians trained
in behavioral principles and techniques (i.e., restraint free environment approach).
Participants included 11 residents (10 female, 1 male) with ethnic backgrounds including 10
Caucasian and 1 Hispanic elder (Mage = 85.6 years, SD = 5.7, range 78–95 years). All
participants had a prior clinical diagnosis of dementia (Alzheimer's type, Vascular, or NOS)
made by their physicians or mental health providers at least 1 year prior to participation in
the study. The reason for referral to the study included staff difficulties managing problems
of depression, agitation, or both in specific residents. Residents were assessed prior to
treatment initiation and weekly thereafter.
Measures
Agitation—Cohen-Mansfield Agitation Inventory-Long Form with expanded descriptions

of behaviors (CMAI: Cohen-Mansfield et al., 1989) was used to assess change in overall
level of agitation from baseline to the end of the evaluation period. The CMAI consists of 29
items reflecting different overt behaviors, such as wandering, spitting, verbal aggression in
individuals with cognitive impairment. The frequency of the behavior is measured on a scale
from 1 (does not engage in the behavior) to 7 (behavior occurs several times per hour) and
refers to the 2 week period prior to the day administered. The CMAI has excellent interrater
reliability with correlations of .88 and .92 in nursing home settings (Cohen-Mansfield et al.,
1989). The CMAI was administered to family members (if available) or the caregiver(s)
who worked most closely with the target client approximately every two weeks. Whenever
possible, a second CMAI was collected for reliability purposes.
Behavioral function—The Motivation Assessment Scale (MAS: Durand, 1986) is a 16-

item questionnaire designed to identify possible functions or motivators for a target behavior
(in this case a specific type of agitated behavior). The purpose of functional assessment is to
identify the maintaining variables for the specific elder's behavior, which are then used in
identifying appropriate treatments. There are three different types of functional assessments,
including indirect (informant), descriptive (focus on topography of behavior; often involve

direct observation of level of behavior), and functional analysis (experimental manipulation
of the environment) (Lennox & Miltenberger, 1989). Indirect assessments such as the MAS
involve use of interviews, rating scales, and questionnaires to assist in the formulation of
hypotheses regarding the function of the target behavior. The four possible functional
categories include sensory, escape, attention, and tangible. Sensory refers to situations in
which the person would engage in the target behavior if the person was alone or unattended
for a long duration of time, or appears to get some enjoyment out of the behavior (e.g.,
“feels, tastes, looks, smells, and/or sounds pleasing” in some way). Escape refers to
situations in which the person engages in the behavior immediately after a demand of some
kind is made on him/her. Attention refers to situations in which the person engages in the
behavior when the staff member is attending to someone else, when staff members stop
attending to this person, or when the staff member is otherwise engaged nearby. Lastly,
tangible refers to situations in which the person seems to engage in the behavior to gain

access to something that the resident was told they could not have (object or activity), when
staff has removed an object, or the behavior stops after the person is given an object that he/
she has requested. The MAS items have been found to have good interrater reliability (.66–.
92) and test-retest reliability (.89–.98) (Durand & Crimmons, 1988). The MAS was used to
identify possible functions of the target behavior for each person and was given to staff
during baseline. The MAS was offered in both Spanish and English versions.
Mental status—The Mini Mental State Exam (Folstein, Folstein, & McHugh, 1975) is a
19-item cognitive screening measure that is commonly used to obtain a gross estimate of
cognitive function. Scores below 24 are indicative of cognitive impairment, with lower
scores indicating more severe impairment. Published research on the MMSE indicates good
reliability; interrater correlations of .82 and test-retest reliability ranging from .89 to .98
(Cockrell & Folstein, 1988; Folstein et al., 1975). The MMSE was administered at baseline
and at post-intervention to track the progression of cognitive decline (if any) over the course
of the study.
Functional status—Katz Basic Activities of Daily Living (ADL) Scale (Katz, Downs,
Cash, & Grotz, 1970) is a brief 6-item scale in which the caregiver rates whether the
participant is able to independently complete a set of activities such as bathing, dressing, etc.
Higher numbers reflect greater independence. The Katz was tracked as a means of
monitoring participant decline in abilities over the course of the study.
Depressed mood—The Cornell Scale for Depression in Dementia (CSDD: Alexopoulos,

Abrams, Young, & Shamoian, 1988) is a 19-item, clinician-scored brief inventory of
depressive symptomology for individuals with a diagnosis of dementia. The score is
informed by information from both the caregiver and the participant with symptoms
evaluated on a 3- point rating scale (0=“absent”, 1=“mild or intermittent”, and 2= “severe”).
Scores of 8 or greater are indicative of significant depressive symptoms. Reliability and
validity scores of the CSDD are good to excellent. Inter-rater reliability kappa for the CSDD
is .67, its internal consistency ratings (.84) are adequate, and its validity was established
based on comparisons with the Hamilton Depression Rating Scale (Korner et al., 2006). For
those participants who were referred for depression or for both depression and agitation, the
CSDD was administered and utilized to evaluate the severity of depressive symptomology at
baseline and post-intervention.
Preferred activities—The Pleasant Events Schedule (PES: Lewinsohn & Libet, 1972)
and the Reinforcer Assessment for Individuals with Severe Disabilities (RAIS-D: Fisher,
Piazza, Bowman, & Amari, 1996) were utilized as structured means to obtain a list of
preferred leisure activities. The PES is a brief, 44-item, structured questionnaire conducted
with the older adult. Participants are required to respond to the yes/no questions that are
designed to elicit interest in a variety of leisure activities.
The RAIS-D is a structured interview designed to obtain a list of specific pleasurable

activities (reinforcers) for which the participant may be interested. The RAIS-D was
originally designed for use with individuals with developmental disabilities, but has been
found to be clinically useful with older adults with dementia (LeBlanc et al., 2006). The
RAIS-D was administered to a staff member and family member (if available). The stimuli
identified by the interview are then ranked by the caregivers in terms of what they believe
will be most preferred by the resident.
Paired-Stimulus Preference Assessments—As previously noted, a preference

assessment is a structured technique for systematically identifying the preferred items in

individuals with verbal and/or cognitive impairments. Eight stimuli are chosen (identified
from the PES and RAIS-D); each item is coupled with another item from the list and
presented in a random order until all possible item combinations had been given. The
therapist records the participant's response to each item, and this response is utilized to
gauge preference (e.g., verbally indicating choice of item, reaching for item). Then the items
are ranked based on the number of times chosen by the participant.
Procedures
The present study involved three phases: 1) baseline measures, 2) intervention, and 3)
evaluation.
Phase 1—Administration of baseline measures. Baseline measures were taken on overall

frequency of agitated behaviors using the CMAI, mental and functional status (MMSE and
Katz ADL, respectively), Cornell Scale for Depression (where applicable) for a measure of
severity of depressive symptomology, possible behavior function (MAS), and preferred
activities (PES and RAIS-D). Following the procedure utilized in LeBlanc et al. (2006),
these interviews were used to create a list of items to be used in the preference assessments
in Phase 2.
Phase 2—Intervention. Intervention included conducting SPA, communicating results to

staff, and developing behavior plans. To determine participant preference, the eight items
that were identified in Phase 1 were presented in a paired-item format following the
procedures in Fisher, Piazza, Bowman, & Hagopian (1992) and were conducted in the
tangible modality. The items were presented in a counterbalanced fashion reflecting the side
that the item was placed on (right or left) to control for side preference and the presence of
hemi-neglect, which could inadvertently affect choices made. The items were then ranked
based on the number of times chosen.
Results of the SPA were communicated to staff and systematically incorporated into
individualized care plans. For example, the results from the MAS were examined with staff
and incorporated into function-based interventions. The items from the SPA identified as the
top four ranked items were communicated to staff and the therapists then engaged in
problem-solving with staff in how to incorporate SPA information into the resident's care
plan. Staff were observed and given corrective feedback during the first day of
implementation of the behavior plans.
Phase 3—Ongoing assessment measures. On-going assessment was conducted to evaluate

whether the preference assessment-informed behavior plan decreased agitated behavior
using the CMAI. In addition, the Cornell Scale for Depression in Dementia (CSDD) was
administered to those participants referred for depressive symptoms. The CSDD was
administered post intervention to assess impact of the behavior plan on depressive
symptomology. The Katz ADL was also administered routinely to track change in functional
status over time.
Research Design
This study used a pretest/posttest experimental design for evaluating the impact of the
intervention on depression and a non-concurrent multiple baseline design across participants
for evaluating the impact of the intervention on agitation. A multiple baseline design is
designed such that measurements are taken on each person during baseline, and then the
intervention is initiated such that each person has a successively longer baseline period
(Kazdin, 1982). Thus the person serves as his/her own control. This design controls for
maturation effects. The key feature of this design is that the behavior should change only

when the intervention is applied and not before, thus providing evidence that the
intervention and not some extraneous variable is responsible for the behavior change. As
each pattern of behavior change is replicated across each successive baseline, this provides a
further demonstration of control. For this reason, multiple baseline designs have an
advantage over other designs (such as ABAB designs) in that the intervention does not have
to be withdrawn to demonstrate control, thus making it more appealing both ethically (in
that you do not have to withdraw an effective intervention) and in terms of its acceptability
to staff. Visual inspection was used to compare baseline data to treatment data to determine
if there was a significant decrease in CMAI, which would indicate a decrease in level of
agitation. The more immediate the change in agitated behavior after introduction of the
intervention, the stronger the demonstration of the power of the intervention.
Results
Eleven older adult participants were included in our study. Seven participants were referred
for agitation and four participants were referred for both agitation and depression. All
participants carried diagnoses of dementia; five were diagnosed with dementia of the
Alzheimer's type, two with vascular dementia, and four with undifferentiated dementia (i.e.,
Dementia NOS) at least one year prior. The mean MMSE score was 7.1 (SD = 7.9, range 0 –
23). The mean Katz ADL scale score was 2.3 (SD = 2.0, range 0 – 5). Our participants
included 9 Caucasian females, 1 Hispanic female, and 1 Caucasian male. Two of the
participants were nonverbal, eight had various levels of verbal ability, and one was Spanish-
speaking only.
The PES was successfully conducted with 8 participants (72.7%) and for the remaining 3
participants either a family member or LTC staff member (i.e., care manager and CNA)
completed it on their behalf (9.1% completed by family members and 18.2% by LTC staff).
The RAIS-D was successfully conducted with either family members and/or LTC staff (i.e.,
CNA's and professional caregivers). The percentage of family members who completed the
RAIS-D was 35.7%. On average, the SPA took about 32.5 min to complete (range 15 – 45).
The majority of cases resulted in clear preferences for some items over others. SPA were
successfully conducted with 9 of the 11 participants. One participant was unable to stay
seated for more than a few minutes at a time before getting up to wander, and the second
refused SPA participation. For the resident who wandered (Caucasian female), the
information on possible preferred activities (as identified by the PES and RAIS-D) was
summarized and provided to the LTC staff as possible items to incorporate in the behavior
plan (e.g., introduce items at predictable times before the resident became agitated). For the
second participant (Caucasian female) who refused the SPA phase and was in a severe
agitated state (i.e., weeping, rocking side to side, and hair pulling), the therapist offered her a
choice of different colored balloons (that had been brought for the preference assessment) in
an attempt to distract her from her agitated behaviors. The participant indicated interest in
the yellow balloon only and when the balloon had been blown up and offered to her, she
began to laugh and was able to engage in a game of balloon toss. Staff were informed of the
results of this interaction and encouraged to use the balloon in future interactions to distract
and redirect her when agitated. Anecdotal reports from staff suggest that this intervention
was successful in reducing her agitation, although her data are not available because of
participant refusal to complete the SPA.
It took approximately 25–30 min to go over the results of the SPA with staff. Staff appeared
receptive to results and reported willingness to implement the interventions. Therapists
observed and coached staff during the first session of utilizing objects or engaging in
preferred activities with the resident.

Individual scores are presented (refer to Figures 1 & 2). Clear reductions in overall CMAI
scores were observed in seven of nine participants who received the intervention, with a
slight reduction in an additional one participant. Interobserver agreement was conducted on
approximately 10% of sessions with two independent caregivers ranking the participants'
agitated behaviors with 90% agreement on overall level of agitation.
In the four individuals who were also referred for depression, pre and post-depression scores
on the CSDD indicated that for Participant 5, a clinically significant change in score was
observed (an 11-point drop), indicating the participant no longer scored in the Major
Depressive Disorder range. For Participant 9, a small decrease in score as reported by the
CSDD was found (a 2-point drop) and no clinically significant change was observed in the
remaining two participants (Participants 1 & 2).
Case Study 1
Mr. Jones is a 74-year-old, Caucasian male, with a diagnosis of moderate to severe dementia
(MMSE = 0), who was referred for “agitated” behaviors. Mr. Jones exhibited frequent
wandering behaviors around the care home and would “fidget” with the doorknobs to the
extent that he tended to break them. Mr. Jones' CMAI score was high at baseline (CMAI =
60).
The MAS indicated that it was likely that the behavior functioned to increase his stimulation
as it tended to occur when Mr. Jones was alone, when staff were busy toileting other
residents, or during the lull after lunch was over.
A tangible paired-choice preference assessment was conducted with Mr. Jones with very
clear results. Mr. Jones consistently chose three items (jazz music, purple fabric, and a blue
boa/fuzzy sash) during the assessment. He took only 2 seconds to choose an item and would
engage with it during the entire period prior to the next trial.
The therapist met with care home staff to discuss the findings from the assessment measures
and the preference assessment. The therapist then brain-stormed with staff to discuss how to
incorporate findings into a behavior plan, discussed how to apply the plan within the care
home, and modeled the plan implementation with the resident. Mr. Jones' conservator was
able to purchase a CD walkman with the jazz music that Mr. Jones used to listen to, a blue
sweater, sweatshirt and shirts, and the team provided the purple fabric in which he showed
interest. The LTC staff were coached to do a “check in procedure” in which they would
introduce these items to Mr. Jones during those times when he was most likely to wander
into other resident's rooms and/or play with doorknobs. Staff identified that he would engage
in these behaviors during periods of low stimulation after meals. Staff members then carried
out the intervention. After a week of introducing the preferred items to Mr. Jones, caregivers
noticed a vast improvement in Mr. Jones' functioning, evidenced by the discontinuation of
his wandering and handling of the doorknobs. His CMAI scores decreased from 60 to 33
within 2 months, indicating that he no longer qualified for agitated status.
Case Study 2
Mrs. Smith is an 84-year-old, Caucasian female, with a diagnosis of moderate dementia of
the Alzheimer's type. She was referred for “agitated behaviors”. Mrs. Smith would
frequently engage in screaming, attempts to elope from the facility, and intermittent
aggression towards staff and residents when they would try to prevent her from leaving the
facility. Mrs. Smiths's CMAI score had increased during baseline and was extremely high at
the end of baseline (CMAI = 83).

The MAS clearly indicated that her behavior functioned to allow her to “escape” during
periods of high stimulation, such as during shift change, meal preparation, and during noisy
group activities like singing or music.
A tangible paired-choice preference assessment was conducted with Mrs. Smith and resulted
in clear results. Mrs. Smith consistently chose three items (flowers made of felt material,
photo album with pictures of her family, and a book with pictures of San Francisco). She
took no longer than a few seconds to choose an item and would engage with the item until
staff removed it for the next trial. She was also able to speak about why she liked the item
and of what it reminded her.
The therapist met with LTC staff to review the findings from the assessment measures and
the preference assessment. The therapist then coached caregivers to present one of these
items to her during times in the day when she seemed to become restless and try to escape
(during periods of high stimulation). Staff then carried out the intervention. Caregivers
found that they could easily redirect her with each of these items before she would get too
restless (i.e., antecedent intervention). They found that once she became agitated, it was
more difficult for them to distract and redirect her, further emphasizing the need to prepare
in advance for times in the day when noisy activities were planned, meals were being
prepared, and when there was high traffic from visitors. Her intervention was slightly
adjusted such that before times of increased sensory stimulation, caregivers engaged her by
presenting preferred items and found that this helped to decrease her attempts to escape. Her
CMAI scores decreased dramatically over 5 weeks from 83 to 34, indicating that she no
longer met criteria for agitated status.
Discussion
Agitation and depression are two of the most difficult behaviors for caregivers to manage
(Fisher et al., 1993) and account for the greatest use of resources. In the current study,
caregivers were given two structured inventories to assist in generating a list of preferred
leisure items and activities. These items were used in systematic choice making
opportunities (SPA) with the person with dementia to determine preferred items that would
be applied in subsequent behavioral plans. The use of structured interviews to obtain a rank
ordered lists of leisure activities has been shown in previous studies to be more accurate than
simply asking caregivers to nominate items possibly because the structure of the interviews
cues caregivers to think of categories of activities that the person may have enjoyed in the
past and does not rely on recall (Fisher et al., 1996). Although this process of obtaining
preferences may take more time in the beginning, it is more accurate and efficient than
simply trying items without prior information of preferences, which may waste valuable
staff time and may lead to inadvertently increasing the agitation level of participants.
Agitated behaviors were operationalized and the hypothesized functions were obtained using
the MAS. These target behaviors were then assessed and tracked over time using the CMAI.
Generally a total score is not used when tracking agitated behavior with the CMAI, rather
criteria are used to determine agitated/not agitated status in three categories: aggressive,
physically nonaggressive, and verbally agitated behavior. However, given that we were
interested in the improvement in the overall level of agitation in our participants, we utilized
a total score as the main criteria for success. Further analyses looking at the agitated/not
agitated status indicate that six participants no longer qualified as agitated, and three
participants still qualified as agitated. However, of those three who remained agitated, one
was discharged to the hospital secondary to systematic infections, one was discharged to the
hospital secondary to severe pain, and the last passed away after contracting pneumonia.
Thus, because of attrition, it is difficult to determine if in the absence of severe physical

illnesses, whether the intervention would have been effective or not for these three
individuals.
Results of the assessments were then communicated to the staff in a 30 min session, and
behavior plans were made collaboratively. LTC staff were able to utilize the MAS to assist
in determining possible functions for the agitated behaviors and identify patterns for when it
might be best to introduce the intervention (e.g., during shift change, after lunch, etc.). This
suggests that with training and encouragement, LTC staff can create and implement
behavioral interventions with good effect. It is important to note, however, that trained
therapists completed the preference assessment procedures, and thus it is unclear from this
study whether or not LTC staff would have the time to be taught how to implement the
procedures and conduct them with integrity.
LTC staff were able to successfully implement behavior plans that incorporated prompts for
activity choice or access to preferred items to reduce depression and agitation in older adults
with dementia. These behavior plans resulted in substantial decreases in agitated behavior
scores as measured by the CMAI. Future research needs to evaluate how well staff can
continue to create these interventions without continued support from behavioral specialists.
Researchers should investigate mechanisms for dissemination of these tools and
interventions to enhance the sustainability of these practices.
We believe that despite the initial time investment needed for training in preference
assessment procedures, the offset in decreased agitation and increased quality of life in
residents merits further investigation. Future research should examine the effectiveness of
training staff in identifying preferred reinforcers for individuals with depression and
agitation. The positive outcomes observed imply that LTC staff should have increased
access to these tools. Staff comfort with conducting assessments and their efficiency in
completing these procedures may be enhanced if preference assessments were part of the
initial intake or admission process and prompts for activity choice (or providing access to
preferred items) became part of the normal care routine. Using preference assessment tools
and related interventions may assist in the treatment and prevention of future episodes of
agitation and therefore reduce caregiver burden related to managing agitation.
In addition, these findings have important implications for increasing quality of life in
individuals with dementia. Having data from preference assessments might result in better
therapeutic outcomes in terms of reduction in agitation, and therefore less need for
medications (e.g., chemical restraint), and may lead to increased activity level of
participants. For example, preference assessments could assist the practitioner in developing
lists of activities that are satisfying for that person. This may assist with promoting more
active involvement of the affected individual with the environment, thereby reducing
depressive symptoms. Thus, preference assessments have potential as both a clinical and
research tool in LTC settings.
Limitations
When examining the multiple baseline graphs, with the exception of participant 1, the
pattern of change occurs when and only when the intervention is applied and is replicated
across participants, lending support that the intervention is responsible for the change in
agitated status. One limitation to this design is reflected in the short baseline periods.
Typically with single case designs, baseline data represent individual behavioral
observations, and three data points are conventionally used to observe a trend. In our study,
we used the CMAI which was a measure of overall agitation level based over a 2-week
period. With such a long observation period, it was not always possible to collect the
conventional number of data points. For several participants it was necessary to intervene

earlier to prevent loss of placement, rather than waiting the 6 weeks necessary to obtain the
three data points. However, despite this limitation, given that the behavior change was in the
desired direction, occurred immediately after administration of the intervention, and was
replicated across baselines, we can be more confident in our results.
For depression the results were far less clear. For two of four participants referred for
depression, behavior plans using preferred items resulted in modest decreases in depression
scores at post-intervention. However, for the remaining two participants, no changes in
depressive symptoms were observed. This was a surprising finding given research
supporting theories of depression related to lack of access to reinforcing events (Lewinsohn
& Libet, 1972) and decreased positive interactions between the person and their
environment (Teri, 1996). Given that this study was designed to both increase participant
access to pleasant and preferred activities and thus increase the positive interaction with
their environment, we would have expected to see decreases in depressive symptomatology.
However, we did not observe every instance in which staff implemented the behavior plans,
and thus it is possible in these cases that either the interventions were not carried out to
fidelity or that the interaction between the caregiver and the participant was not positive.
Another potential reason that the intervention does not seem to have been as effective in
decreasing depressive symptoms may be related to the fact that indicators of depression in
persons with dementia are often more difficult for others to observe and report (Forsell,
Jorm, & Winblad, 1993). The CSDD contains many behavioral indicators of depression, but
some indicators still require the subjective evaluation of the reporter (e.g., poor self-esteem,
pessimism).
We were unable to complete the preference assessments with two of the participants. One
limitation of this study relates to the possibility that those two participants who were unable
to complete the preference assessments may have been the most agitated. This could
indicate that preference assessments may not have utility in the cases of severe agitation.
However, this has not been empirically demonstrated. Future investigators may want to
evaluate use of preference assessments in individuals with differing levels of agitation.
Unfortunately, both of these participants were moved to higher levels of care due to physical
ailments before the interventions could be implemented. It would have been interesting to
discover whether the interventions would have been as effective in decreasing agitation and
depression without having knowledge of the final ranking of preferred items. Anecdotal
evidence suggests that this is a possibility. An alternative interpretation is that these two
participants were unable to sit still long enough to complete the preference assessments.
This could indicate that the means by which the preference assessments are administered
may need to be altered in those participants who wander. For example, the assessment could
be completed while walking with the participant. To our knowledge this has not been
attempted in the published research. Future research should investigate the effectiveness of
alternate formats for conducting preference assessments in individuals who wander.
Strengths
This study adds to the current literature on preference assessments and agitation
management in an applied setting. Much of the previous literature on preference assessments
has focused on either identifying and predicting potential reinforcers to be used in
subsequent interventions in individuals with developmental disabilities (Hagopian et al.,
2004) or increasing engagement in individuals with dementia (Leblanc et al., 2006). There
are no studies to our knowledge that have looked at the utility of using preference
assessments as part of an intervention in the management of depression and agitation in
older adults with dementia.

In many types of research a final sample size of eight would be considered a limitation.
However, in single case design research this is not the case. With multiple baseline designs,
the minimum requirement is two baselines (e.g., participants), and three baselines are even
stronger as the number of baseline affects the number of opportunities for replication of
results. In our study, we saw replications in eight of nine baselines, providing evidence of a
powerful intervention.
These results suggest that a relatively quick and simple procedure for evaluating preferences
for leisure activities/items can be utilized in simple interventions to reduce agitation in
individuals with dementia in a LTC setting and may be effective for reducing depression, as
well. Given the success of using SPA to identify preferred items to be used in interventions
to decrease difficult behaviors that occur at a high rate, it may be possible to use these same
procedures to increase prosocial behaviors that occur at a low rate. Once preferred items are
identified from the preference assessments and individuals are given access to these
preferred items contingent on certain behaviors, these items could then be used to reinforce
and strengthen adaptive behaviors. There is evidence that the procedures can be successfully
used in this fashion in research with individuals with developmental disabilities (Fisher et
al., 1996). Future research should investigate this as a possibility, as increasing adaptive
behaviors is likely related to increased access to positive social reinforcers and positive
interaction with the environment.
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Figure 1.
Scores on the Cohen-Mansfield Agitation Inventory for Participants 1–3 (upper figure) and
for Participants 4–6 (lower figure).

Figure 2.
Scores on the Cohen-Mansfield Agitation Inventory for Participants 7–9.

Table 1
Facility demographics for number of beds, staffing ratios, and number of participants referred
Facility Number Number of beds Staff to Resident Ratio Number of participants in study
1 20 2:5 4
2 24 5:6 1
3 19 7:19 2
4 60 3:10 2
5 86 5:17 1
6 95 7:19 1

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Clin Gerontol. 2009 ; 32(3): 239–259. doi:10.1080/07317110902895226.

Applications of Preference Assessment Procedures in

Currently, depression is one of the most common disorders/neuropsychiatric symptoms seen

As previously mentioned, dementia results in progressive declines in multiple areas of

Clin Gerontol. Author manuscript; available in PMC 2012 May 14.

SPA can be administered in multiple formats, including basing preferences on caregiver

Clin Gerontol. Author manuscript; available in PMC 2012 May 14.

Agitation—Cohen-Mansfield Agitation Inventory-Long Form with expanded descriptions

Behavioral function—The Motivation Assessment Scale (MAS: Durand, 1986) is a 16-

including indirect (informant), descriptive (focus on topography of behavior; often involve

Clin Gerontol. Author manuscript; available in PMC 2012 May 14.

Depressed mood—The Cornell Scale for Depression in Dementia (CSDD: Alexopoulos,

The RAIS-D is a structured interview designed to obtain a list of specific pleasurable

Paired-Stimulus Preference Assessments—As previously noted, a preference

Clin Gerontol. Author manuscript; available in PMC 2012 May 14.

Phase 1—Administration of baseline measures. Baseline measures were taken on overall

Phase 2—Intervention. Intervention included conducting SPA, communicating results to

Phase 3—Ongoing assessment measures. On-going assessment was conducted to evaluate

Clin Gerontol. Author manuscript; available in PMC 2012 May 14.

Clin Gerontol. Author manuscript; available in PMC 2012 May 14.

Clin Gerontol. Author manuscript; available in PMC 2012 May 14.

Clin Gerontol. Author manuscript; available in PMC 2012 May 14.

Clin Gerontol. Author manuscript; available in PMC 2012 May 14.

replicated across baselines, we can be more confident in our results.

Clin Gerontol. Author manuscript; available in PMC 2012 May 14.

Clin Gerontol. Author manuscript; available in PMC 2012 May 14.

dementia patients in long-term care facilities. Clinical Gerontologist. 1993; 13:3–12.

Clin Gerontol. Author manuscript; available in PMC 2012 May 14.

Clin Gerontol. Author manuscript; available in PMC 2012 May 14.

Clin Gerontol. Author manuscript; available in PMC 2012 May 14.

Clin Gerontol. Author manuscript; available in PMC 2012 May 14.

Clin Gerontol. Author manuscript; available in PMC 2012 May 14.

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